What are the primary care recommendations for a 57-year-old male with hypertension, weighing 195 pounds?

Primary Care Management of Hypertension in a 57-Year-Old Male

Initial Assessment and Blood Pressure Targets

For this 57-year-old male with hypertension, the primary blood pressure target should be <130/80 mmHg if well-tolerated, with a minimum acceptable target of <140/90 mmHg. 1

• Confirm the diagnosis with home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) if not already done 2
• Assess for target organ damage including left ventricular hypertrophy, chronic kidney disease, and retinopathy 3
• Screen for secondary causes if blood pressure is severely elevated (≥160/100 mmHg), including primary aldosteronism, renal artery stenosis, and obstructive sleep apnea 2
• Evaluate cardiovascular risk factors including fasting lipids, diabetes screening, and smoking status 4

Lifestyle Modifications (Essential First-Line Therapy)

All patients with hypertension require intensive lifestyle modifications regardless of medication use, as these interventions provide additive blood pressure reductions of 10-20 mmHg. 3

Dietary Interventions

• Sodium restriction to <2 g/day (approximately 5 g salt/day or <100 mmol/day) provides 5-10 mmHg systolic reduction 3, 5
• Follow a DASH-style diet emphasizing fruits, vegetables, low-fat dairy products, whole grains, and reduced saturated fat 4, 5
• Increase dietary potassium intake through food sources 1

Weight Management

• Target BMI 18.5-24.9 kg/m² and waist circumference <102 cm for men 3, 4
• At 195 pounds (88.5 kg), assess height to calculate BMI and determine if weight loss is indicated 3
• A 10 kg weight loss produces approximately 6.0 mmHg systolic and 4.6 mmHg diastolic reduction 2

Physical Activity

• Perform 30-60 minutes of moderate-intensity aerobic exercise 4-7 days per week 4, 5
• Regular aerobic exercise provides 4 mmHg systolic and 3 mmHg diastolic reduction 2

Alcohol Limitation

• Limit consumption to ≤14 standard drinks per week for men 4, 5
• Alternatively, restrict to <100 g/week (approximately 7 standard drinks) 3

Pharmacological Management

First-Line Monotherapy Selection

For initial pharmacological therapy in this 57-year-old male without compelling indications, start with a thiazide or thiazide-like diuretic, ACE inhibitor/ARB, or long-acting calcium channel blocker. 1, 4

Preferred Initial Agents:

• Thiazide-like diuretic: Chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes) 3, 2
• ACE inhibitor: Lisinopril 10-40 mg daily or enalapril 5-20 mg daily 1, 4
• ARB: Losartan 50-100 mg daily or candesartan 8-32 mg daily 1, 5
• Calcium channel blocker: Amlodipine 5-10 mg daily 2, 1

Dual Therapy (If Monotherapy Insufficient)

Most patients require combination therapy to achieve blood pressure targets, and adding a second agent from a different class is more effective than increasing the dose of a single agent. 2, 1

Recommended Two-Drug Combinations:

• ACE inhibitor or ARB + calcium channel blocker 2
• ACE inhibitor or ARB + thiazide diuretic 2, 4
• Calcium channel blocker + thiazide diuretic (particularly effective in Black patients) 2

Triple Therapy (If Dual Therapy Insufficient)

The guideline-recommended triple therapy combination is: ACE inhibitor or ARB + calcium channel blocker + thiazide diuretic. 3, 2

• Start with chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 25 mg daily as the third agent 3, 2
• Optimize doses of existing medications before adding a fourth agent 2
• Check serum potassium and creatinine 2-4 weeks after initiating diuretic therapy 3, 2

Resistant Hypertension (Blood Pressure Uncontrolled on Triple Therapy)

If blood pressure remains ≥140/90 mmHg despite optimal doses of three medications including a diuretic, add spironolactone 25-50 mg daily as the preferred fourth-line agent. 3, 2

• Spironolactone provides additional blood pressure reductions of 20-25/10-12 mmHg when added to triple therapy 2
• Monitor potassium closely when combining spironolactone with ACE inhibitor or ARB due to hyperkalemia risk 3, 2
• Verify medication adherence before adding a fourth agent, as non-adherence is the most common cause of apparent treatment resistance 3, 2

Monitoring and Follow-Up

Initial Monitoring

• Reassess blood pressure within 2-4 weeks after initiating or modifying therapy 3, 2
• Achieve target blood pressure within 3 months of treatment initiation or modification 3, 2
• Check serum potassium and creatinine 1-4 weeks after starting ACE inhibitor, ARB, or diuretic 3, 2

Long-Term Monitoring

• Once blood pressure is controlled, monitor every 3-6 months 4
• Annual screening for target organ damage and cardiovascular risk factors 4
• Encourage home blood pressure monitoring for ongoing assessment 2

Cardiovascular Risk Reduction Beyond Blood Pressure Control

Lipid Management

• Screen fasting lipids in all hypertensive patients and treat dyslipidemia according to cardiovascular risk 4, 5
• Consider statin therapy for high-risk patients even without dyslipidemia 5

Antiplatelet Therapy

• Once blood pressure is controlled to <140/90 mmHg, consider aspirin 75-100 mg daily for cardiovascular protection 5
• Do not initiate aspirin until blood pressure is adequately controlled due to increased bleeding risk 5

Critical Pitfalls to Avoid

• Do not combine ACE inhibitor with ARB - this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit 2, 5
• Do not use beta-blockers as first-line therapy in the absence of compelling indications (angina, post-MI, heart failure, or need for heart rate control) 3, 2
• Do not delay treatment intensification - prompt action is required when blood pressure remains above target to reduce cardiovascular risk 3, 2
• Do not add multiple agents before optimizing doses of current medications - this violates guideline-recommended stepwise approaches 3, 2
• Avoid NSAIDs, decongestants, and other medications that interfere with blood pressure control 2